90 Day Leadership Action Plan
90-Day Action Plan
(October 1-Dec 31, 2009)
Group: Partners in Improving Quality and Measuring for Excellence Date: October 22, 2009
|Category |IPCC Goals |90-Day Action Steps |Team Members |Result/Measure of Success |
| | | | | |
|Daily Goals |Achieve 100% compliance with daily goals |Identify outcomes measure (e.g., avoidable delays, |Leader: Lesta |Clearly defined measure and data collection process |
| |communication sheet |communication with sub-specialty teams, follow-through of |Jonathan Seigel |RT and CM compliance improved |
| | |goals) |Heather |No copies are being used (originals kept at door) |
| | |Determine best way to educate and encourage RTs and CMs |Jane |Revised daily goals sheet |
| | |compliance |Sara | |
| | |Refine process & form for completion with new rounds |Lupe | |
| | |structure | | |
| | |Pilot involvement of one new sub-specialty team | | |
| | |Coordinate with Rapid Response Committee to improve family|Leader: Jonathan Slagle |Improved family awareness rates |
|Partnering with |Establish a family member as part of PIQME |education |Doreen |Feedback data from families |
|Families |Achieve 100% compliance with daily |Complete information-gathering projects: survey/interview |Roger |Recommendations on FCC structure for PICU |
| |communication of goals with families and |of PICU families, lit review and FCC organization study |Hadley |Focus group scheduled |
| |patients able to participate |Plan for focus group |Ken | |
| |Increase family/patient awareness of PRRS | | | |
| |from 40% to 85% | | | |
| |Reduce average ICU length of stay by 10% |Fully implement new rounds structure |Leader: Tina |Clearly defined measure and data collection process |
|Standardizing Rounds |Improve efficiency (time) of bedside ICU |Mean length of rounds to hold steady (or reduce by 10-20%)|Benny |Rounds structure implemented and mean length reduced |
| |rounds by 30% |Determine outcome measure |Jonathan Seigel |Training video developed |
| |Improve satisfaction of staff participating |Refine data collection process (use second ½ of resident |Lesta | |
| |on rounds |rotation period) |Lindsay | |
| | |Video new structure to help with education and |Jane | |
| | |implementation |Chris, RT | |
|Infection Rates: |Decrease VAP rate per 1000 ventilator-days by|Continue hand hygiene audits |Brad (VAP) |Rates continue to decrease for VAP & CLABSI |
|CLABSI, VAP, UTI |an additional 25% |If rates increase, develop reaction plan such as root |Roger (CLABSI, UTI) |Rates showing improvement for UTI |
| |Decrease CLABSI rate per 1000 central |cause analysis |Tina Adams (as needed) | |
| |line-days by additional 25% |Include report out from Six Sigma UTI team at PIQME | | |
| |Decrease catheter-associated urinary tract |meetings | | |
| |infections per 1000 catheter-days by 10% | | | |
|Program Management |Develop a coordinated approach for |Define LOS measure for peds cardiac patients and establish|Tina, Erin, Ashley |Clearly defined measure and data collection process |
| |implementing a system-wide model to improve |baseline | |Quarterly report distributed |
| |the quality and safety of care for critically|Develop and distribute quarterly report (internal | |Communication plan implemented |
| |ill pediatric patients at the NC Children's |communication) | |IRB approval received |
| |Hospital |Meet with Karen to discuss internal and external | |Plan for sustainability efforts |
| | |communication | | |
| | |Submit IRB determination form for approval | | |
| | |Identify strategies for obtaining continued support for | | |
| | |IPCC | | |
| | | | | |
| | |Note: Operational definition for communication of daily | | |
| | |goals with patients & families to be developed next | | |
| | |quarter | | |
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